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<br /> � ' Building Permit A►ppiica�io� for IVeainte�a�ce / Reno�a�ion � 4
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<br />'�� (windows, doors, si�iing, re-roof, efc.)
<br /> Mailin Address: ��
<br />_�: ��v 0,� PO Box 66 Permit number: vZ0 /'j —CJO d� �
<br /> Crystal Bay, MN 55323-0066 Date received: � �J /�� �
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<br /> ��a �'a y�;, s, Street Address: Received by: �
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<br /> �'�n �,�'a„ �� 2750 Kelley Parkway Plan review fee: �
<br /> L�s �"r�w Orono, MN 55356 �'�
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<br /> Total Fee: ��o� , (P 9 �
<br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us a�
<br /> ;,` This application form must be completed in full and all required information must be submitted. ,�
<br /> Incompiete applications will be returned. (Please print) �
<br /> ` GENERAL INFORMATION: I
<br />� ' Job Site Address: ��� �r� ,, l�.v� �����l�V�- �
<br />`� Will this be a Parade of Homes, Remod�le s Show se Home or other Disp�ay Home? ❑ Yes ��No '
<br />�"' !f yes,a special event permit is required with Poiice Department and City Counci/approval 60 days prior to the event. Shuttle bus service wilf be
<br /> � required unless appficanf demonstrates sufficient on-site parking is availab/e. Non-permifted events will nof be allowed. ;$
<br /> ��
<br /> CONTRACTOR/APPLICANT INFORMATIO�l: �
<br /> Name:
<br /> State License# Expiration Date: �
<br /> Lead Certification Number: Expiration Date: �
<br /> ' (for work on homes fhat were consfructed prior tSy 978 �;�
<br /> � Phone: (office) (cell �°
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<br /> Maifing Address: City: ZIP: ��
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<br /> `' Contact Person: / � Applicant is: Contractor / Homeowner (Cirde One) ��
<br />��� Email and/or Fax: � `��
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<br /> PROPERTY OWNER NFORMAT\ N: ��;
<br /> Name: �� , �rl-- �:'�
<br /> `� Phone (day): r�-Z-3 � P`
<br /> " Address: ^ ��
<br /> �. �21� �D ��� 2.2--Crt �.o. City: ��(,rl�� ZIP: .5�.�.� f �'
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<br /> '' Email and/or Fax �_-� ���� � Co�„` `�'
<br /> i��c � aw.lj�nsv� . Y '4<'s"�' �:
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<br />" ` PROJECT INFORMATION: :�
<br /> Type of Project: Any earth movement may require _�fi;
<br /> ❑ Door(s) ❑ Remodel ❑ Fire Damage MCWD review& permits: �
<br /> R� Minnehaha Creek Watershed District(MCWD) x
<br /> ❑ Re-roof, asphalt ❑ Re air ��
<br />�;� p ❑ Storm Damage 18202 Minnetonka Blvd ;�.;
<br /> ❑ Re-roof, cedar ❑ Restorafion ❑Water Qamage Deephaven, MN 55391 ;
<br /> ` Phone: 952-471-Q590 `
<br /> "L�' ❑ Re-roof, other(specify) ❑ Siding ❑ Other: (specify} Fax: 952-471-0682 "4
<br /> � ❑Window(s) www.minnehahacreek.orq :}
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<br /> �� Overall Project Dsscription: , 5;��� ��, �,y ;� �
<br /> Esfirnated Construction ValuaEion of Project(excfuciing land) $"Z.ac�o '"�
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<br /> �": APPLICANT ACKNOWLEDGEMcNT: �w
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<br /> ��: • Agrees to provide all information required or requested by fhe Building Department; ��
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<br /> • Certifies that the information supp(ied is true and correct to the best of his/her knowledge. The appficant recognizes that they ! �
<br /> �� are solely responsibie for submitting a complete appiication being aware that upon failure to do so, the staff has no alternative
<br /> �.,
<br /> but to reject it until it is complete; r;�
<br /> • Some or alf of the information that you are asked to provide on this appfication is classified by State law as either private or
<br /> confidenfial. Private data is information which generally cannot be given to the public but can be given to the subjecf of the ,q,
<br /> �y data. Confidential data is information which generally cannot be given to either the pubfic or the subject of the data. Our E;
<br /> purpose and intended use of this information is to annualfy update our records and records of other governmental agencies �
<br /> re �ired b law. If vou refuse to su pl the information,the a pfication mav not be issued. T�
<br /> � �;j
<br /> AppficanYs Signature: `—� Qate: � Z-- �,
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<br /> Last Updated: 08-09-2011 ,
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